Provider Demographics
NPI:1124634266
Name:BRUNELLO, LAURA K (MOTR/L)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:K
Last Name:BRUNELLO
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2257 N ASTAIRE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3807
Mailing Address - Country:US
Mailing Address - Phone:208-891-7104
Mailing Address - Fax:
Practice Address - Street 1:3080 E GENTRY WAY STE 180
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3014
Practice Address - Country:US
Practice Address - Phone:208-939-3334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1525225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics